Youth Completing Adult Trial Membership Intake

Adult Trial Membership - AGES 15-17

Intake form for Brazilian Jiu Jitsu and or Fitness
- Trial Membership Price - $137
- This trial membership is nonrefundable - even if your child refuses to attend or participate
- You can choose to participate in Jiu Jitsu or Fitness classes (or both - there is no price difference)
- A trial membership does not automatically rollover into membership
- Bring a filled water bottle to classes (we do not have a water fountain)
- Have your child wear comfortable activewear
- If using a loaner gi for Brazilian Jiu Jitsu, please arrive 10 minutes before class to allow time to be fitted.
- Parents are not allowed in the classroom setting or to view from the hallway to reduce distractions. There is a lounge just around the corner from the mats you can wait in.
After completing and signing this form, you will be directed to a secure website to make your payment. If payment isn't made, intake forms are not recorded.

An Impact team member will reach out to schedule initial classes. Please allow at least 24 hours to be contacted and if registering over the weekend or holiday, please allow until the next business day.
Name of Parent or Legal Guardian*

First NameLast Name
Parent or Legal Guardian Mobile Number*
Please enter a valid phone number.
Email*
example@example.com
Name of Minor Child*

First NameLast Name
Birthdate*

MonthDayYear
Date
Programs of Interest*
Briefly share past history with fitness, sports or martial arts.
List any current or past health issues/injuries/behaviors (and approximate date) you want to share with our coaches.
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
I certify and represent that I am the parent or legal guardian of the minor child listed on this form.

I agree that all training and safety recommendations given to my minor child listed are undertaken at the sole risk of myself. Newberg BJJ, LLC dba Impact Training Center (referred to as GYM) is not liable for any claims for injuries or damages, whatsoever, to my minor child or property arising out of, or in connection with attending and participating in classes provided by GYM, or any actions taken within the facility outside of a coach’s supervision or without permission. On behalf of my named minor child, I agree to indemnify and hold harmless GYM, its owner, employees, subcontractors, and representatives from all claims of liability by me.

I agree my named minor child will abide by any rules and regulations issued by GYM. Failure to do so may result in expulsion from training and the forfeiture of all monies paid to the GYM.

I give GYM the irrevocable right to use video or photograph in all forms of media, including composites for social media, advertising, publication, or any other lawful purposes, and waive any right to inspect or approve the finished product, including written copy created in connection with the image. GYM will not publish the names of minor children with said images without my consent or that of another parent/legal guardian.

The Gym, owner, agents, and employees shall not be responsible for damaged, lost or stolen articles, inside or outside the facility.

I understand this is a waiver and release of liability and I voluntarily agree to its terms.
Signature*

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Adult Trial Membership - AGES 15-17